HomeMy WebLinkAboutPermit Mechanical 1993-09-30."j clTY OF OBEGO'V
LIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAPETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
r Ii|GFIELO
0ffice:
INSPECTION LTNE:
726-3759
726-3769
Job Location:
Assessors H"p *t t1 3ar-.lL..l Tax Lot #: f:?.Too
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Ovner:
Address z 34 L,/1)]q otJ\+^
Ci ty:State:
Va1ue o St /Pellet Stove/Insert:a<_
Phone *:+
Zipz )./ 1')
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( pleas ec rcle appropriate appli ance)
Preriminary rnspection is $15.00 (prior to instalration of insert)lJood stove/perret/rnsert permit i"'$rs.oo .-gidloo t."u"n"" *-$.?5 state surcharge.
Type of Inspection Requested: LAJcCrcy'-.il.,W_
Contractor 3
Address:Phone {t:
Ci ty:State:zi p:
Construction Contractors Registration *:lres:
By signing this permit(726-3769). I state tthat I vas provided vi
appliances and prelimif am installlng meets
Environmental Qualityprovide the testing apalso understand that i
may be required to be ,
/application, I agree to caII for an inspection(s) as requiredhat arr information on this apprication/p..rii -i"
"orr""t andth the llood stove safety infoimatton for wood burningnary inspection standards. r further state that the-appriancesmoke emission standards as set by the oregon Department ofor the Federar Environmentar protlction aglncy "na r agree toprovar number to the inspector at the timl of- inspection. rf r am_requesting a preriminary inspection, ttre r.rarr coveringremoved.
REQUTRED rNSPEsrroN(s) :
^\
UOODSTOVE/-----/
Date of Application: Q la^1
Total Amount CoIIected z 3 aS?S
Receipt #:Uq?s
a lz-nlo'^
Date
FOR OFFICE USE
PELLET/INSERT ). PRELIMINARY
Job *z Q 'A lSn<.
0
ture
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Checked for Delinquencies:
Issued By:
Checked for Historical Status:
*t-qo
Permit No
Address:
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lssued by hB
OR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONS!BILITIES
Note: Oregon Law, ORS 701.055(4) , requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
A
1
2
gnature rm cantpp
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
ZL+L N Aq@SU
qlulqt
Q -',r^ -qz
Date
3 My general contractor is ,
Contractor registration numbe
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
3.B I will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
I hereby certify that the above inlormation is correct and that I have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.II (I1
Date:
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT